Definition

What is Extrapyramidal symptoms?

Extrapyramidal symptoms are forms of abnormal body movements that can occur in people taking antipsychotic medications. They are more commonly caused by typical antipsychotics, but can and do occur with any type of antipsychotic.

The four main types of extrapyramidal symptoms are Parkinsonian Symptoms, Dystonia, Akathisia, and Tardive Dyskinesia.

How common is Extrapyramidal symptoms?

Please discuss with your doctor for further information.

Symptoms

What are the symptoms of Extrapyramidal symptoms?

Parkinsonian symptoms

You have the same symptoms as someone with Parkinson’s disease, but your symptoms are caused by medications, not by the disease. These symptoms may include tremor, slower thought processes, slower movements, rigid muscles, difficulty speaking and facial stiffness.

Dystonia

Your muscles involuntarily contract and contort. This can lead to painful positions or movements.

Akathisia

It is a feeling of restlessness, making it hard to sit down or hold still. Symptoms include tapping your fingers, rocking, and crossing and uncrossing your legs.

Tardive dyskinesia

This condition makes have uncontrollable facial movements such as sucking or chewing, lip smacking, sticking your tongue out or blinking your eyes repeatedly.

There may be some symptoms not listed above. If you have any concerns about a symptom, please consult your doctor.

When should I see my doctor?

If you or your loved one has any signs or symptoms listed above or you have any questions, please consult with your doctor. Everyone’s body acts differently. It is always best to discuss with your doctor what is best for your situation.

Causes

What causes Extrapyramidal symptoms?

Extrapyramidal symptoms are caused by a blockade of normal dopamine functions in the brain. They occur most commonly as side-effects of certain medications that block dopamine functioning, such as the Typical Antipsychotics, or less commonly, the Atypical Antipsychotics. Antidepressants and other medications can sometimes cause extrapyramidal symptoms as well.

Extrapyramidal function refers to our motor control and coordination, including being able to not make movements we don’t want to make.

Risk factors

What increases my risk for Extrapyramidal symptoms?

Extrapyramidal symptoms are often found in people with Schizophrenia and Bipolar Disorder who use these medications. However, these symptoms can also occur in people with Schizophrenia who have never taken any of these medications.

Please consult with your doctor for further information.

Diagnosis & treatment

The information provided is not a substitute for any medical advice. ALWAYS consult with your doctor for more information.

How is Extrapyramidal symptoms diagnosed?

It is difficult to measure extrapyramidal symptoms. Rating scales are commonly used to assess the severity of movement disorders. Please consult with your doctor further information.

How is Extrapyramidal symptoms treated?

Treating Parkinsonian symptoms:

The first step is to try to reduce the dose of the antipsychotic medication that may be causing the Parkinsonian symptoms. If this does not work, one option is to switch the medication to a different antipsychotic that has less potent dopamine-blocking actions. Quetiapine and Clozapine are the antipsychotics with the least dopamine-blockade, followed by Olanzapine.

The second option is to add an anticholinergic medication. The anticholinergic medication will need to be used on a daily basis in order to control the Parkinsonian symptoms. It should be used at the lowest possible effective dose, and once the Parkinsonian symptoms subside it can be tapered and discontinued, as sometimes the Parkinsonian symptoms will improve with time.

Treating akathisia:

The first step is to try to reduce the dose of the antipsychotic medication that may be causing the akathisia. If this does not work, one option is to switch the medication to a different antipsychotic that has less potent dopamine-blocking actions, such as Quetiapine, Clozapine, or Olanzapine.

A second option is to add a medication to treat the akathisia. Propranolol used at low doses is a first-line option [ref, ref], though there is some evidence that Mirtazapine used at 15mg nightly can be as effective and better tolerated. Benzodiazepines have been shown to be effective at least for short-term relief of akathisia. Although anticholinergics are sometimes used for treating akathisia, there is actually no evidence that this is effective.

Treating dystonia:

A person with a dystonic reaction should be brought to medical attention immediately as it is considered a medical emergency, especially if it is affecting the person’s neck or head muscles or their ability to breathe easily. Dystonia can be relieved quickly and effectively with an intramuscular dose of an anticholingergic (eg. Benztropine at 1-2mg, repeated every 15-30min as required until the dystonia resolves). For dystonias that are mild but that tend to occur repeatedly or continuously, the same treatment approach should be used as for Parkinsonian symptoms described above.

Treating tardive dyskinesia:

Tardive dyskinesia takes months or years to develop, and once it sets in it can be very difficult to treat. For this reason, the best treatment of tardive dyskinesia is prevention. Choosing antipsychotics with low dopamine-blocking action, such as the Atypical Antipsychotics – especially Quetiapine and Clozapine, as well as Olanzapine – would be the options with the lowest risk of causing tardive dyskinesia. Once tardive dyskinesia has set-in, the main treatment option is to switch the antipsychotic to one with lower dopamine-blocking action; again, Quetiapine and Clozapine would be the best options in this regard. Initially, this may cause the tardive dyskinesia to become more pronounced, but over the course of several weeks the dyskinesia should improve.

Various medications have been proposed over the years for treating tardive dyskinesia, but most of them do not have good enough evidence to support their use in clinical practice. Tetrabenazine is one medication that may be beneficial for some patients.

Lifestyle changes & home remedies

What are some lifestyle changes or home remedies that can help me manage Extrapyramidal symptoms?

If you have any questions, please consult with your doctor to better understand the best solution for you.